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Precancers and Skin Cancers

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Presentation on theme: "Precancers and Skin Cancers"— Presentation transcript:

1 Precancers and Skin Cancers
Adam O. Goldstein, MD, MPH Associate Professor Family Medicine University of North Carolina at Chapel Hill

2 Actinic Keratoses premalignant skin lesions = “keratinocytic intraepidermal neoplasia” chronic sun, radiation or polycyclic aromatic hydrocarbons Skin Type I-II organ transplant

3 Actinic Keratosis

4 Actinic Keratoses Distribution: Sunexposed, esp. dorsa hands/forearms
Description: papules,plaques with scale and erythema, occasional crust or cutaneous horn Sandpapery feel

5 Actinic Keratoses epidermal atypia abnormal maturation

6 Actinic Keratoses 60% predisposed >40 have at least 1 AK
6-10% lifetime >> invasive SCC >10 AK - 14% an SCC w/n 5 yrs 60-97% of SCC from AK ~ 40% of met SCC>> AK ^ aggressive immsupp

7 Actinic Keratoses lip lesions: actinic cheilitis/leukoplakia
white plaques-mucosa persistent scaling lesions on the lip ^ aggressive behavior tobacco/sun

8 Differential Diagnosis
squamous cell carcinoma: more indurated, thicker, recurrence of AK after treatment

9 Differential Diagnosis
seborrheic keratosis: hyperpigmented,more stuck on appearing

10 Differential Diagnosis
nummular eczema: coin-shaped scaling lesions; responds to emollients/topical corticosteroids

11 AK Treatment PREVENTION Screen for skin cancers Broad-brimmed hats
sun protective clothing sunscreens avoidance of sunlight ed s/sx skin cancer avoidance of tobacco low fat diet?

12 AK Treatment 5-fluorouracil cream or solution Diclofenac Sodium-3% gel
Cryosurgery(liquid nitrogen) 5-fluorouracil cream or solution Diclofenac Sodium-3% gel Imiquimod 2 x week/ 16 weeks

13 AK Treatment Excision Electrocautery Curettage Carbon dioxide laser

14 AK Treatment Photodynamic therapy Retinoids-topical/oral
Chemical peels Photodynamic therapy Retinoids-topical/oral Investigational-dimericine

15 TREATMENT Liquid Nitrogen-Advantages cure rates of 98.8% common
minimal patient ed multiple/thicker lesions quick recovery

16 TREATMENT Liquid Nitrogen-Disadvantages storage pain
pigment alteration training

17 5-Fluorouracil Cure 50-80% Blocks methylation reaction of deoxyuridylic acid to thymidilic acid DNA (and RNA) synthesis

18 Diclonfenac Sodium 3% Topical Gel
mechanism of action unknown NSAID inhibition of cyclo-oxygenase >>>PGE-2 90 days BID--overall 33-47% clearance vs 10-19% vehicle avoid ASA triad hypersensitivity

19 Photodynamic therapy (Pariser DM - J Am Acad Dermatol -2003)

20 Salasche SJ et al Am Acad Dermatol 2002;47:571-7.
Cycle therapy of actinic keratoses of the face and scalp with 5% topical imiquimod cream: An open-label trial. Significant irritation Rest periods required Evolving protocols Expensive Effective Salasche SJ et al Am Acad Dermatol 2002;47:571-7.

21 Skin Cancer Statistics
>1 million cases/yr >50% of all new cancers 1 in 5 Americans will develop skin cancer

22 Types of Skin Cancers Basal Cell Carcinoma - 80%
Squamous Cell Carcinoma - 16% Melanoma - 4%

23 BCC /SCC Most common skin cancers Most important risk factors
sun exposure family history skin type Incidence of these cancers increase with age, probably related to cumulative sun exposure

24 Basal Cell Carcinoma the most common skin cancer
90% appear on face, ears, head

25 Main Types Basal Cell Carcinomas
Nodular BCCs - most common type Sclerosing BCCs (morpheaform) Superficial BCCs

26 Pattern of Nodular BCC raised pearly white, smooth translucent surface with telangiectasias

27 Pattern of Nodular BCCs
may ulcerate leaving a small bloody crust may be pigmented

28 Pattern of Sclerosing BCCs
ivory or colorless flat or atrophic indurated may resemble scars are easily overlooked

29 Pattern of Sclerosing BCCs
ivory or colorless flat or atrophic indurated may resemble scars are easily overlooked

30 Pattern of Superficial BCCs and SCC in situ
red or pink scaling plaques occasionally with shallow erosions or crusts differentiation between these two similar lesions usually requires a biopsy

31 Pigmented BCCs may look like melanoma increased brown or black pigment
seen more commonly in dark-skinned individuals

32 Differential Diagnosis of Nodular BCC
Intradermal nevus Sebaceous hyperplasia Fibrous papule of the face trichoepithelioma

33 Differentiating Intradermal Nevus from Nodular BCC
Stable size Soft No crusting or ulceration May have telangiectasias

34 Differentiating Intradermal Nevus from Nodular BCC
Stable size Soft No crusting or ulceration May have telangiectasias

35 Sebaceous Hyperplasia from Nodular BCC
yellow coloration stable size umbilication without ulceration is hard to see after injecting anesthesia

36 Diagnosis of Basal Cell Carcinomas
Shave biopsy nodular thick superficial types Punch biopsy morpheaform flat superficial types

37 Treatment options for Basal Cell Carcinomas
C + D after a shave biopsy Cryotherapy with thermocouple if you have experience Excision with 3- 5 mm margins Superficial trunk/ext: imiquimod qd x 12 wks Mohs for recurrent BCC and areas of cosmetic importance

38 Mohs micrographic surgery
removal of tumor by scalpel in sequential horizontal layers. each tissue sample is frozen, stained, and microscopically examined repeated until all the margins are clear treatment of choice for BCCs with poorly defined margins especially those on the nose or eyelids

39 Recurrence rates after Tx of BCCs
C + D 10% Cryotherapy 10% Excision 2 - 5% Imiquimod ??? Mohs <1%

40 Factors that increase recurrence rates
sclerosing vs others larger size of BCC margins experience of the surgeon

41 Sclerosing BCC is most dangerous
tend to be deeply invasive often not diagnosed until they have caused extensive damage invade muscle, nerve, and bone nodular BCC can also invade deeply

42 Bowen’s disease - features
SCC in situ Mainly sun exposed areas Slightly elevated red scaly plaque with well-demarcated borders

43 Bowen’s disease - features
May resemble psoriasis, superficial BCC, chronic eczema, SK Curable using C & D, cryo, 5-FU, imiquimod, excision

44 Keratoacanthoma Appear suddenly, grow rapidly
Central crater with keratin plug May grow to 2cm in size May resolve spontaneously May look like SCC

45 Keratoacanthoma C and D elliptical excision 5-FU topically tid
5-FU intralesional injection

46 Location of SCCs Same distribution as bccs.
Especially on the lips, ears, and scalp Initially grow by direct extension Metastasize to local lymph nodes and then to distant sites

47 SCCs with an increased risk of metastasis
larger, advanced lesions SCC on mucous membranes (in the oral cavity, on the lips) BCCs rarely metastasize

48 SCC more aggressive (local & mets)
Size >2 cm SCC in a scar Patient is immunosuppressed Poorly differentiated There is perineural invasion

49 Importance of early diagnosis of BCC and SCC
especially in facial cancers the nose is the single most frequent site of BCC reconstruction is difficult extension into underlying bone and cartilage may occur

50 The differential diagnosis of superficial BCC and SCC in situ
Actinic keratosis, nummular eczema Nummular eczema can usually be distinguished by its coin-like shape, transient nature, and itchiness Biopsy any thickened and crusting actinic keratosis to rule out BCC or SCC

51 Treatment options for SCC
C + D after a shave biopsy cryotherapy with thermocouple if you have experience excision with 5 mm margin Mohs for recurrent SCC and areas of cosmetic importance

52 Erythroplasia of Queyrat
SCC in situ on the penis Usually under the foreskin of the uncircumcised penis May occur on the vulva 5-FU, imiquimod or mohs

53 Indications for Referral for Mohs Surgery

54 Indications for Referral for Mohs Surgery
Recurrent tumors, sclerosing BCC Primary tumors in locations with high tumor-recurrence rates Nasolabial fold,temple, periauricular area, periocular area, scalp, nasal alae, center face Preservation of normal tissue is vital (for cosmetic and functional reasons) Nose, eyelids, lips, fingers, ears, penis

55 When to consider referral
Aggressive and recurrent skin cancers A large skin cancer lesion A lesion located in a sensitive area (cosmetic or functional) When treatment or diagnosis of the lesion is beyond the scope of one’s skills If mohs surgery is the treatment of choice

56 Melanoma Risk Factors Family history Personal history Atypical Nevi
Blistering Sunburns Type 1 skin

57 History of a changing lesion

58 Melanoma Statistics Fastest rising incidence rates
Most common cancer in 25-9 y/o 2nd only to breast CA in 30-4 y/o women

59 Melanoma Facts 87,900 new cancers 7400 deaths in 2003 due to melanoma
34,300 in situ 53,600 invasive 4% increase from 2001 7400 deaths in 2003 due to melanoma

60 Melanoma

61 Melanoma-Early detection
Total treatment costs by stage Stage I 5.5% Stage II 5.5% Stage III 34% Stage IV 55%


63 Melanoma with regression

64 Melanoma

65 Acral lentiginous Melanoma

66 Lentigo Maligna Melanoma

67 Venous Lake

68 Blue Nevus

69 Seborrheic Keratosis

70 Pyogenic Granuloma

71 Look everywhere

72 Melanoma Management Excisional “biopsy” 1-2 mm margins
Dermatopathologist consultation

73 Breslow’s Measurement
Depth of granular cell layer to deepest malignant cell Strongest correlation with prognosis

74 Melanoma Managment Sentinel lymph node biopsy
1mm or greater depth, regression, >Level III or IV Interferon Vaccine clinical trials

75 Melanoma Management Full skin exam Family screening Follow up

76 Take home points Prevent skin cancers by risk factor reduction
Early detection of pre-cancers and skin cancers can prevent morbidity and mortality Use the appropriate biopsy technique for diagnosing skin cancers Treat or refer based on your skills

77 Online References Derm Online Atlas is at Derm Image Bank is at Basal Cell Carcinoma is at

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